How to Reduce the No-Show Rate in the Psychiatric Oncology Clinic: Clinical Safety and Effectiveness Project

Cancer diagnosis and treatment are life-changing experiences, and patients need help to appropriately manage them. Anxiety, depression, and treatment-related side effects may demoralize cancer patients and alter their quality of life. Patients may experience existential despair and hopelessness and lose their sense of meaning in life (1). Oncologists are well trained in managing the biomedical aspects of care but may not always be aware of the psychological and social challenges their patients face. Providing mental health support may improve adherence to cancer treatment, leading to better outcomes. Cancer care today provides state-of-the-science biomedical treatments, including immunotherapy, targeted therapy, and several hundred experimental phase 1 treatments. These newer treatments come with unknown side effects and complications, which compromise cancer patients’ quality of life. Mental health care embraces patients’ emotional, psychological, and social well-being; when patients are confronted with cancer diagnosis and treatment, it is important to stabilizes these factors. The loss of certainty, physical dependence on others, low self-esteem, financial burden, loss of hope, and threat of death are common emotional experiences of cancer patients (2). Failure to receive mental health care along with cancer treatment may compromise the effectiveness and outcome of the treatment. Improving engagement and providing adequate and consistent mental health care to cancer patients is of paramount importance. These principles, universally endorsed by the National Comprehensive Cancer Network (3), affirm the importance of psychological health. Access to the best mental health care can improve patients’ quality of life and end of life (4, 5). However, for optimal medication adjustment and psychological and emotional support, patients are required to attend multiple psychiatry visits.

Our psychiatric oncology clinic, located in a cancer hospital, stabilizes patients by providing appropriate medication and emotional support and by motivating them to adhere to treatment. Along with dependency and role reversal, cancer patients often experience despair and isolation and lose their sense of identity, freedom, and meaning in life. Two therapists in our psychiatric oncology clinic have been trained to address existential despair and provide supportive psychotherapy, practicing logotherapy and cognitive therapy and offering psychoeducation to enhance meaning and spiritual well-being for patients. The inpatient psychiatry team is available as a consult service to provide mental health services to inpatients and to patients receiving care in other hospital-based specialty clinics in the institution. To communicate the importance of mental health stability for cancer patients, the inpatient psychiatry team collaborates with social workers and other specialists throughout the institution to promote mental health awareness through monthly educational programs and poster presentations.

When a patient is overwhelmed with multiple medical appointments or is fatigued from the oncology treatment itself, he or she often misses mental health visits. A meta-analysis by DiMatteo et al. (6) concluded that patients with depression were three times less likely to adhere to medical recommendations regarding drug therapy and clinic appointments than were patients without depression. Failure to attend routine mental health appointments can result in functional impairment and increased risk of hospitalization (7) and may interfere with medical treatment. To improve attendance in the psychiatric oncology clinic, a quality improvement team was organized in our psychiatric oncology clinic to identify and address barriers to mental health care and to implement and sustain strategies to overcome these barriers in order to improve patients’ adherence to medical treatment.

Design and Implementation

The team designed a 5-month quality improvement project to increase attendance at mental health visits in the psychiatric oncology clinic at a leading comprehensive cancer center in Houston. The psychiatric oncology clinic is open during business hours, and after-hours service is provided by the on-call psychiatrist. The clinic’s six full-time psychiatrists and two therapists provide services for oncology patients. The quality improvement team for this study consisted of one psychiatrist, one therapist, and one scheduler.

The quality improvement team carried out the project in four phases. First, the team assessed the clinic’s no-show rate. Schedulers called patients who missed appointments to find out the reason for the no-show and to reschedule the appointments, keeping track of the patients’ reasons for missing their appointments and their preferences for future clinic appointments. In addition, the team conducted a literature search to identify common reasons for missed mental health appointments.

In phase 2, the team identified potential root causes of missed appointments through a brainstorming activity and patient feedback (a fishbone diagram is available in an online supplement). We then categorized the causes of missed appointments (i.e., financial, scheduling, communication, or personal issues). The team prioritized and addressed financial and scheduling problems and devised and implemented strategies to improve patients’ engagement in mental health care.

During phase 3, the team reviewed the improved no-show rate, and the successful strategies were sustained. The team addressed secondary no-show reasons one by one and implemented further strategies to improve attendance. During phase 4, the team standardized the successful strategies for all providers in the clinic. We individualized interventions to meet patients’ needs. In situations where the patient felt fatigued or was detained in another clinic yet needed to be seen by a mental health provider, we dispatched the inpatient psychiatry consultation team to provide supportive services.

Reasons for Missed Appointments

We categorized the reasons patients did not show up for appointments as financial, scheduling, communication, and personal. The team prioritized interventions to address the first two barriers and tracked their impact on appointment adherence.

Financial barriers and strategies to overcome them.

Patients reported several financial reasons for no-shows. One of the main barriers to mental health clinic attendance was insurance coverage. Patients without mental health insurance coverage often avoided outpatient psychiatric visits. Many insurance companies cover mental health services only during hospitalization for another reason. Some insurance companies pay for a set number of mental health clinic visits per year, and once a patient reaches the maximum number of visits, the coverage is annulled. Other financial reasons for missed appointments included the costs of parking, gas, food, and psychotropic medications.

The quality improvement team developed strategies to address financial concerns, handling each barrier individually. The team worked closely with the institution’s business offices to secure insurance approval prior to patient appointments. Other financial concerns were addressed by prescribing low-cost psychotropic medications and generic medications, and when insurance allowed, 3-month mail order supplies were prescribed. The institution’s Department of Social Work helped mobilize resources for free or inexpensive transportation, and patients were encouraged to purchase discounted weekly parking passes.

Scheduling barriers and strategies to overcome them.

Inconvenient scheduling was a common problem, especially for patients traveling long distances. Patients who were already coming to the hospital several times a week often preferred to skip a freestanding psychiatry appointment. Having numerous medical appointments on the same day or having a mental health visit on a day without other appointments were major factors affecting the no-show rate. After reviewing appointment schedules, the team found that psychiatry visits scheduled after chemotherapy were often missed, presumably because patients felt fatigued after infusions, and we made efforts to improve scheduling.

In response to these findings, we coordinated psychiatry appointments with other appointments, but not on days when a patient was booked all day in other clinics. We honored patient requests for a specific day when possible. We tried to minimize long waits between appointments, and we scheduled appointments before chemotherapy to avoid no-shows because of postinfusion fatigue. The team scheduled follow-up appointments before patients left the clinic. As we implemented advance financial clearance and amenable scheduling, appointment adherence increased.

Communication and personal barriers and strategies to overcome them.

Other reasons for no-shows were as follows: patients did not have access to reminders that were e-mailed or left on their cell or home phone; patients were sick at home, hospitalized, delayed in another clinic, or tired after having multiple appointments; patients, especially young adult men, felt stigma at being seen in the mental health clinic; and patients encountered obstacles in securing transportation. Another barrier to attendance at psychiatry appointments was patient perception of the derived benefit of attending the mental health clinic when undergoing challenging cancer treatment.

The team identified the importance of implementing better communication practices. Two reminder calls were sent out 7 days before the appointment via an automated appointment reminder system. These reminders were reinforced by a scheduler who sent a reminder e-mail 2 days before the appointment. Patients were encouraged to cancel appointments at least 2 days in advance if they were unable to attend their scheduled appointment. Providers began honoring appointments for late arrivals whenever possible. The addition of an aquarium and large plants were suggested to reconfigure the seating arrangement and reduce patient visibility as a way of addressing the stigma of being seen in a mental health clinic.

One of the challenges the team faced was patients’ inability to understand the significance of mental health stability; they either failed to identify their mental health issues or they disregarded the importance of addressing them. The team engaged these patients and their caregivers through social workers, educated them on the benefits of mental health stability and how stable mental health could improve outcomes and help them cope with treatment side effects. Thus, they were encouraged and motivated to remain compliant with mental health visits. Overall, by addressing these issues and by taking patients’ scheduling preferences into consideration, we were able to improve cancer patients’ engagement in mental health care.

Postintervention Evaluation

After implementing these strategies for 10 weeks, the no-show rate in the clinic dropped. We evaluated the improvement in patient attendance by comparing equivalent 10-week time periods. The total number of patients seen during a 10-week period before implementing these strategies was 555 patients out of 718 scheduled appointments. After implementing the strategies, the number of patients seen in 10 weeks rose to 643 of 767 patients scheduled. Thus, the attendance rate improved from 77% to 84% after the strategies were implemented. The total number of patients increased by 51 when compared with an equal number of patients scheduled for the equivalent period. Encouraged by this improvement, the team met again. We looked at other barriers and implemented additional strategies to further improve attendance, which have now become ongoing tasks in the clinic.

Discussion

Last-minute cancellations and missed appointments negatively affect clinic flow. They add financial burden by increasing collateral work by clinicians and schedulers to contact patients and reschedule appointments. The quality improvement team at our psychiatric oncology center successfully identified and addressed barriers to attendance at mental health visits, implemented and retained strategies that improved appointment adherence, and continues to examine potential opportunities for improvement.

The importance of integrating mental health services into ongoing medical care has been recognized. In our institution, this integration has been achieved by assigning social workers to all medical oncology clinics, inpatient hospital units, and emergency departments to provide around-the-clock coverage. Each physician in the outpatient oncology clinic has a social worker on his or her team who evaluates patients and recommends psychiatric consultations as needed. For inpatient medical and/or surgical oncology teams, all hospital units have social workers assigned to the area. Inpatient social workers attend morning meetings with medical and/or surgical oncology teams, often attending rounds, evaluating patients, and recommending psychiatry consultations if needed.

Our findings should be interpreted in light of certain limitations. Because this project was initially limited to 10 weeks, the results presented show improvement for a limited period. Since then, our clinic has sustained the strategies implemented to continue improved adherence to mental health visits. A longer period of tracking would allow for a more in-depth analysis of behavioral patterns and additional strategies to reduce missed appointments in the mental health clinic. The no-show rate was calculated only from scheduled patients who did not call to cancel. It is possible that patients with advanced disease undergoing intense treatment may have cancelled the clinic visit in advance. Patients who were very sick or terminally ill may have given up on accessing mental health services.

Conclusions

These findings indicate that implementing strategies to overcome barriers to attending mental health appointments and to improve communication with patients helped to reduce the no-show rate in our psychiatric oncology clinic. Future studies should test this approach by integrating mental health services within oncology clinics. Ultimately, improving the no-show rate will lead to successful treatment outcomes and better quality of life for cancer patients.